USA Department of Defense audit of surgical antibiotic prophylaxis prescribing patterns in inguinal hernia repair.

PURPOSE: Antibiotic prophylaxis in inguinal hernia repair (IHR) is contentious in literature and practice. In low-risk patients, for whom evidence suggests antibiotic prophylaxis is unnecessary, many surgeons still advocate for its routine use. This study surveys prescription patterns of Department of Defense (DoD) general surgeons. METHODS: An anonymous survey was sent electronically to approximately 350 DoD general surgeons. The survey asked multiple-choice and free text answers about prescribing patterns and knowledge of current evidence for low-risk patients undergoing elective open inguinal hernia repair without mesh (OIHRWOM), open inguinal hernia repair with mesh (OIHRWM), or laparoscopic inguinal hernia repair (LIHR). RESULTS: 110 DoD general surgeons consented to participate. 58.6, 95 and 84.2% of surgeons always administer antibiotic prophylaxis in OIHRWOM, OIHRWM, and LIHR, respectively. 37.9, 70.9, and 63.2% of surgeons believe that it reduces rates of surgical site infection in OIHRWOM, OIHRWM, and LIHR, respectively. The most common reasons for empirically prescribing antibiotic prophylaxis include "I think the evidence supports it" (27 of 72 responses), "I would rather be conservative and safe" (15 of 72 responses), and "I am following my hospital/department guidelines" (9 of 72 responses). 11.8, 40.8, and 32.9% of surgeons believe current evidence supports antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. 50, 18.4, and 22.4% of surgeons believe current evidence refutes antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. CONCLUSION: The survey results indicate that the majority of practicing DoD general surgeons still empirically prescribe surgical antibiotic prophylaxis in IHR despite more conflicting opinions that it has no meaningful effect or that current evidence does not supports its use.

Heterotopic ossificans in chronic venous insufficiency: a new consideration for clinical, aetiology, anatomy and pathophysiology staging.

OBJECTIVES: Heterotopic ossification is defined as the abnormal formation of true bone within extra-skeletal soft tissues. It may be associated with a variety of clinical conditions, but is most frequently seen with musculoskeletal trauma, neurologic injury or genetic abnormalities. It has also been described in patients with chronic venous insufficiency; however, it often goes underdiagnosed due to chronic ulceration that masks exam findings. To date, few reports of heterotopic ossification due to chronic venous disease exist within the literature with the most recent dating back to the 1970s. METHODS: We present a case study of a man presenting with extensive leg ulceration and a history of chronic venous insufficency. He had a large non-healing venous stasis ulcer of the left lower extremity with extensive heterotopic ossification discovered intraoperatively. RESULTS: The patient was managed with serial wound debridement, innovative woundcare and eventual split thickness skin grafting that achieved limb salvage despite the complexity of his wound. CONCLUSIONS: Our discussion focuses on the epidemiology, pathophysiology, diagnostic work-up and management of heterotopic ossification in the setting of chronic venous insufficiency. We propose that heterotopic ossification be included in any future modifications of the clinical, aetiology, anatomy and pathophysiology system classification as a complication of chronic venous disease.